Breathing New Life
By Yael D Sherman 08PhD
Maternal and Newborn Health in Ethiopia Partnership
Lynn Sibley first saw the infant coffins at the market in Bolivia.
They were for sale alongside brightly colored vegetables, beads, and woven fabrics. She started seeing them everywhere.
“I thought to myself, I don’t want to be a tourist anymore,” she says.
Now a professor in the Nell Hodgson Woodruff School of Nursing, Sibley has devoted her career to reducing maternal and infant mortality around the world. She founded and directs the Center for Research on Maternal and Newborn Survival, which is part of the Lillian Carter Center for Global Health and Social Responsibility.
Sibley recently published the results of a pioneering program—the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP)—in the Journal of Midwifery and Women’s Health. Funded by an $8.1 million grant from the Bill and Melinda Gates Foundation, the program uses a participatory approach to create community-driven best practices to help families in resource-scarce areas.
The grant illustrates the power of private philanthropy to make a difference. “She’s changing lives,” says Ken Hepburn, professor at the School of Nursing. “This approach could change the course of women’s and newborn infants’ lives on a global scale.”
After practicing midwifery for six years as a faculty member at the University of Colorado, Sibley sought graduate training in anthropology to conduct research and undertake applied work in global health. For her dissertation research, she examined traditional midwifery in Belize.
“Having practiced as a midwife in the United States, I had romantic notions of traditional midwifery,” she says. Instead of intervening as little as possible, however, the traditional birth attendants manually dilated the woman’s cervix and pushed down on her belly to help the baby move down—practices understood by medically trained care providers to be potentially dangerous.
Sibley realized that the birth attendants had a radically different view of the body and processes of labor. They believed that when the belly got hard, the baby was trying to come out. They viewed the uterus as a passive organ that required external help, and that understanding guided their practice. Sibley also witnessed the failure of government training of traditional birth attendants—who had been taught to use gloves to prevent infection, but touched everything in the room while wearing the gloves; and were taught to use a bulb syringe to help clear the baby’s nose and mouth just after birth, but blew in rather than sucking out.
“There was no common space of agreement,” Sibley says. “The government training was not fully successful because it did not account for the world view of the traditional birth attendants regarding how the body works during labor and birth.”
With a deep understanding of the challenges of traditional home births, Sibley helped create the Home-Based Lifesaving Skills program for the American College of Nurse-Midwives. Using a skills-based participatory approach, the program teaches home birth attendants about basic techniques that don’t require expensive tools. Sibley led the first field test of the program in India. Today the program is used in twenty countries including India, Ethiopia, Bangladesh, and Belize.
In 2000, Sibley and another colleague from the American College of Nurse Midwives were invited by Save the Children to implement the program in Ethiopia. She returned during the next four years to follow up. During this time she met Abebe Gobyzayehu, a pediatrician and faculty member at Ethopia’s Debub University and Sibley’s coprincipal investigator and project director for the Maternal and Newborn Health in Ethiopia Partnership.
Ethiopia has one of the world’s highest rates of maternal and newborn mortality. Most women give birth at home because the population is largely rural, with very few doctors and nurses. In 2011 only 10 percent of women gave birth with a skilled provider in attendance, and only 7 percent received care within two days of giving birth.
Building on the earlier work of Home-Based Lifesaving Skills, the program aimed to improve the capacity and confidence of frontline health workers to provide maternal and newborn health care, increase the demand by women and families for maternal and newborn health care, improve self-care behaviors, and demonstrate a district model of continuous care improvement.
The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) effectively linked households to health facilities and was driven by health service and community leaders working together. In November 2009, Sibley received the Gates grant, which allowed her to expand her work within the existing Ethiopian health care system.
Drawing largely from her earlier project in Ethiopia, Sibley put together a team of Ethiopian experts to help run the new program. Gobyzayehu took the lead in Ethiopia as the project director. Lelissee Tadesse—one of Sibley’s former trainees—also joined the effort.
In 2000, Tadesse was a newly minted eighteen-year-old nurse with midwifery training. Initially resistant to the training, she quickly saw the results of working with families and grasped the importance of participatory training. She eventually became the senior maternal and newborn health adviser on MaNHEP’s team.
“Lynn had the vision for MaNHEP and put together a team that would flesh it out,” says Hepburn. “She enabled them to take the lead in the areas where they had expertise.”
Sibley and her team trained health extension workers and supported them while they, in turn, trained traditional birth attendants and community health care workers, who were paired to form a guide team. Based in their own communities, guide teams worked with pregnant women and their family members—including husbands—through a series of structured meetings focusing on care before, during, and soon after birth.
“If you want to improve maternal and newborn outcomes, you need to create a space for real dialogue and learning that starts with what people already know and do,” Sibley says.
Meeting four times in each family’s home, the guide team asked about family members’ experiences with birth-related problems, what they did, and what happened. Then the team shared what a trained health worker would do in that situation. Using pictorial checklists and role-play, family members practiced different scenarios, such as resuscitating a newborn.
A leading cause of maternal death in Ethiopia is postpartum hemorrhage, which can kill a healthy woman in two hours. Most people know women who bled too much after giving birth and died. Traditional beliefs hold that too much bleeding is a sign of a spirit who has come to steal the woman’s life, and the way to fight the bleeding is to frighten off the spirit.
After discussing the family members’ experience with hemorrhage, the guide team taught them how to do uterine massage and other basic nursing practices, and how to transport a woman who is bleeding to a health facility using local means, a litter.
Community improvement teams consisting of district health service staff and area leaders—elders, administrative council members, women’s association heads—drove efforts to improve maternal and newborn health care using a collaborative approach. They supported the guide team family meetings and figured out the best practices to ensure that women received adequate care at each stage of birth. “For anything to last, it has to come from the people themselves, and it has to be theirs,” Sibley says.
The partnership paid off. “Women used to think of coming to a health facility as bothering others or creating trouble for the health workers,” says Habtam Gedif, a health extension worker in Mecha. “Now they’ve realized the importance of health care and are demanding more services.”
Frontline health workers’ knowledge, skills, and confidence improved tremendously, and women’s use of any antenatal care increased from about 48 percent to 86 percent, while their use of postnatal care increased from 24 percent to 75 percent. There was a substantial shift in the care providers women used—away from unskilled family members and traditional birth attendants to health extension workers and other professional health care providers.
Perhaps most encouraging, fewer babies died—the interval between newborn deaths began to increase significantly about nine months into the program.
“The training made the pregnant woman herself the center of our focus,” says Asmarech Desta, a health extension worker in Abukeku. “We now stay longer with the women and provide them with personalized care to meet their needs in prenatal care, assist them during the birth process, and offer emotional and physiological support.”
The regional health bureaus and district health offices, with minimal support from the MaNHEP team, introduced and spread the program to seventy-four additional villages in the two regions.
Local ownership of the project extends to authorship and publication as well. “Half of the articles published in the special edition of the Journal of Midwifery and Women’s Health have Ethiopian first authors,” Hepburn says. He traveled to Ethiopia three times to run writer workshops for the first-time authors and created a work plan to develop the articles.
“Writing a research paper gives you a new lens for understanding the project,” Gobyzayehu says. “We learned how to document success stories, which indicators are the most important, and how to write about projects in the future.”
A second MaNHEP project is now underway in Afar, a remote pastoralist region in the desert. This version is using the same model, but has added antenatal care and maternal nutrition to the program—counseling, iron, and folic acid, as well as deworming pills, to prevent anemia.
“Small changes can save the lives of mothers and children,” says Gobyzayehu. “When you work with a community, you can implement basic interventions that make a difference.”
“In a way, this is midwifery on a different scale,” Sibley says. “It’s about supporting and nurturing growth and possibility. I think about practicing midwifery again, then I realize I’m doing it now.”